Application for Access to Dataset

I would like to apply for access to the following data sets:

Data set names/IDs:
COVIDDSL_________________________________________
_________________________________________________
_________________________________________________

I - Contact and Project Information (to be submitted by applicant)

A. Name of applicant (principal investigator), including affiliation and contact details.

Please ensure that a full postal address and a valid institutional email are included.

Name:
Title:
Position:
Affiliation:
Institutional E-mail Address:
Mailing Address:
ID Document Type: Passport / Driving Licence / DNI / Social Security Nr / Other (1)
ID Number:
ID issued by: Specify Country
ID Date of issue:
ID Expiration Date:

B. Name of the authorised institutional representative, including affiliation and

contact details. Please ensure that a full postal address and a valid institutional email
are included.

Name:
Title:
Position:
Affiliation:
Institutional E-mail Address:
Mailing Address:
ID Document Type: Passport / Driving Licence / DNI / Social Security Nr / Other
ID Number:
ID issued by: Specify Country
ID Date of issue:
ID Expiration Date:
C. Names of authorised personnel (within your institution*)
Include the names of all investigators, collaborators and research staff who will have
access to the data in order to work on the project (see Research Project under E).
Please
ensure that a valid institutional email address for each name is included along with
their job title/function.

Name: (copy and paste as needed for additional personnel)

Title:
Position:
Affiliation:
Institutional E-mail Address:
ID Document Type: Passport / Driving Licence / DNI / Social Security Nr / Other
ID Number:
ID issued by: Specify Country
ID Date of issue:
ID Expiration Date:

*Co-investigators or collaborators at other institutions must submit a separate

Application for Access to the Data.

D. Names of authorised students (within your institution*)

Include the names of all students who will have access to the data in order to work on
the project (see Research Project under E). Please ensure that a valid email address for
each name is included.

Name: (copy and paste as needed for additional students)

Title:
Position:
Affiliation:
Institutional E-mail Address:
ID Document Type: Passport / Driving Licence / DNI / Social Security Nr / Other
ID Number:
ID issued by: Specify Country
ID Date of issue:
ID Expiration Date:

*Students at other institutions should not be included in this list.

E. Title of project (within which data will be used)

Please provide the address of the project website as well, if available

F. Research track record

Include a list of up to 3 relevant publications of which you were an author or a co-
author.

-2-
G. Research Project (scientific abstract)
Please provide a clear description of the project and its specific aims, including an
explanation of the role the accessed data will play in answering the research question,
in no more than 500 words.

H. Legal and regulatory requirements

- Recipient may not start the study without prior approval of the ethics
committee, notifications and further legally required approvals.
- The project will not infringe any patent, copyright, trademark, or other rights
- The data provided by HM Hospitales is to be used strictly for the Research
Purpose.
- It is expressly prohibited to reuse the data partially or totally for commercial or
non-commercial use.
RECIPIENT assumes the following commitments:
- Respect intellectual property rights and moral rights of the investigators
- Identify the source of the data correctly: HM hospitales
- To inform HM Hospitales of the project results
- Publish the results of the research
- Preserve the confidentiality of the data
- Correctly safeguard all the documentation provided
- To delete the information once the project has finished
- To compliance with applicable personal data protection in accordance with the
European Data Protection Regulation 2016/679, of April 27, 2016.
- HM Hospitales may disclose the institutions requesting data.

Note (1): Fields in grey refer to official ID Documents and are mandatory for performing
Identity Check of applicants by third parties service providers.

Source: Acuerdo de Acceso de Datos de SANGER.

-3-
BY THE INSTITUTION…….. BY THE RECIPIENT’s Scientist
LEGAL REPRESENTATIVE

Signed: Signed:
Date Date

 
In accordance with the provisions of Regulation (EU) 2016/679 of 27 Abril 2016 (GDPR), data
of those who subscribe and sign the present contract and/or researches with access to data
contained in the database of Covid Save Lives, will be processed by the parties with the sole
purpose of managing their development and to fulfil legal obligations arising therefrom.
These data will be retained for the necessary time in order to comply with the corresponding
legal responsibilities. The parties, signers and researchers are informed of the possibility of
exercising their rights of access, rectification, erasure and portability of the data and those of
limitation or opposition to their processing in the terms provided for in the data protection
regulations, upon accreditation of their identity, by writing to HM HOSPITALES 1989, S.A., and
if they consider that the processing of personal data does not comply with the current
legislation, they also have the right to file a claim with the Supervisory Authority
at www.aepd.es. DPO: dpo@hmhospitales.com.

-4-